AAC awareness training for staff in schools and settings.

Do you have a Child or Young person (CYP) using a communication aid who is due to start in your class or setting?

Are you familiar with AAC and how to support a CYP in your setting?

You can register for a short presentation that has been designed with new team members in mind.

Focus on CYP moving to a new class or setting with a new team of staff (open to the team around the child or young person) such as teachers/ sencos/ teaching assistants/ key workers, and any LSLT's new to post etc.

Book Here:

No current dates, Please check back here for future dates.

The Research office is located within the Learning & Research building here at Southmead Hospital.

Just a stone’s throw away from the Brunel building where most of our patients are treated, Learning & Research is home to an array of facilities that provide medical and healthcare training, teaching accommodation and dedicated study space, as well as a full suite of research facilities.

The building was completed in 2014, alongside the redevelopment of Southmead Hospital, and features sleek interior spaces and a vibrant external design by Avanti Architects. This purpose-built facility represents the Trust’s ongoing commitment to research and is shared between NBT staff and the medical students of Bristol University.

Alongside our office base in Learning & Research, we also manage the adjacent Clinical Research Centre. If you’re taking part in one of our research studies, one of our staff may direct you there as a part of your visit. Our Clinical Research Centre enables us to:

• Look after our research participants in a tranquil and calm environment outside of the main building.
• Bring together researchers from all disciplines from across the Trust, enabling them to work more closely and share best practices.
• Develop the next generation of registered nurses and allied health professionals.
• Give our research participants the best possible experience of taking part in a research study at the same time being given additional advice and support about their diagnosis.

Our team strives to be welcoming, friendly and offer the best possible experience of taking part in research. We look forward to your visit.

Travel information can be found by visiting the Our Hospitals page of our website.

Information for patients

If you have any questions after reading this information, please speak to your nurse.

Why you are having IV iron

You have been found to be anaemic with low iron levels. IV iron is given to patients when oral iron does not work or is poorly tolerated, or where iron stores need to be built up quickly e.g. in preparation for an operation. Anaemia, with the associated risk of a blood transfusion during/after an operation, is associated with poorer outcomes and improving your iron stores helps treat that anaemia.

How IV iron will be given

• Your vital signs (blood pressure, temperature, pulse and oxygen levels) will be taken before you receive IV iron.
• The IV iron will be given as an slow injection through a cannula (plastic tube) inserted into your hand/arm; the injection is given over 30 minutes.
• Your vital signs will be taken again after the injection and you will be observed for 30 minutes to make sure you feel well.

Please let your nurse know if you feel unwell whilst the injection is running.

Possible side effects with IV iron

Like all medicines IV iron can cause side effects.

Common (may affect up to 1 in 10 people)

• Nausea
• Rash
• Discomfort at the cannula site during the injection
• Irritation or mild infection at site of injection
• There is a 1 in 10 chance of leaking of iron into the skin at the site of the injection (extravasation), which causes permanent staining of the skin

Uncommon (may affect up to 1 in 100 people)

• Headache, fatigue
• Flushing, fever, shivering
• Non allergic reaction (Fishbane): symptoms may include facial flushing, chest tightness, shortness of breath and/or joint pains. This usually settles quickly if the injection is stopped and/or continued more slowly.
• Dizziness, blurred vision, altered sense of taste, numbness
• Stomach pain, vomiting, diarrhoea, constipation
• Low or high blood pressure, or increased heart rate
• Hives and itching
• Low phosphate levels

Rare (up to 1 in 1000 people)

• Palpitations, hoarseness, tremor, seizure
• Flu like illness a few hours to a few days after the injection e.g. fever, aches and pains in muscles and joints
• Serious allergy (anaphylaxis): swelling of face, mouth, tongue and difficulty breathing

Please seek medical help if you feel unwell at home within 48 hours after the injection or experience any of the above side effects badly.

The clinical service is staffed with 5 Consultant Haematologists for interpretation and advice.  The technical and clinical service is provided by Biomedical Scientists (BMS), Clinical Scientists (CS) , Associate Practitioners (APs) and Medical Laboratory Assistants (MLA).  The annual workload is in excess of 700,000 request items per year with 8-10% growth each year.  The Department has been approved for Biomedical Scientist and Clinical Scientist Training by the HCPC.  The BMS staff are State Registered with HCPC and the Trainee BMS staff are trained in accordance with the IBMS and HCPC regulations.  There is active encouragement for staff to follow further education courses e.g. MSc (Haematology) and management qualifications.

The Department is well equipped with modern instrumentation and has a replacement program to maintain and improve the level of service provided.

The Department is UKAS accredited and assessed for compliance by MHRA against the Blood Safety and Quality Regulations 2005 and also participates in all appropriate External Quality Assurance Schemes accredited to ISO17043 for which performance is closely monitored.

Clinical Head of Service
Dr Alastair Whiteway

Blood Sciences Manager
Mrs Allison Brixey

Blood Sciences Operational Manager
Mrs Joanne Skingley

What is trans anal surgery?

Trans anal surgery involves the removal of a rectal growth through the anus. It has been performed since the mid-1980s. For many years it has been a specialist operation only available in a few centres. More recently, there have been advances in technology to allow more surgeons to be able to use this technique.

When is trans anal surgery performed?

It is usually indicated in patients who have a benign polyp that is deemed too large to be removed in the endoscopy department. It may also be recommended for removal of a rectal polyp where the endoscopist has recommended that the polyp should be removed in one piece. This ‘one piece’ excision may not be possible endoscopically.

The benefits of removing a polyp in one piece is that when it is looked at under the microscope, the pathologists will be able to truly say whether the polyp has cancer in it or not. This evaluation is not possible when a polyp is removed in several pieces.

A small percentage of patients who are diagnosed with rectal cancer may be offered trans anal surgery. This may be in combination with radiotherapy. This would be as an alternative to major surgery which usually requires patients to have a stoma bag.

What other tests are necessary before the operation?

Usually it will be necessary to perform a flexible sigmoidoscopy or colonoscopy prior to trans anal surgery. This will allow us to gain accurate information about the growth we are trying to remove. If we are worried about the possibility of an underlying rectal cancer, we will arrange a CT and MRI scan.

Most patients are prescribed medication to cleanse the bowel on the day prior to the operation. This will involve taking 2 sachets of powder which is mixed with water. Other drinks such as orange squash and cordial can be mixed with it to improve the taste which some may find unpleasant. The reason for cleansing the bowel is to ensure that there are clear views of the growth during the operation.

What does the operation involve?

The operation is performed under general anaesthetic by keyhole surgery and takes between 1 and 2 hours.

All patients have a temporary urinary catheter inserted at the start of the procedure. A 4cm flexible port is inserted into the anal canal to allow the surgeon to use standard keyhole equipment. As with a colonoscopy, gas is used to keep the rectum widely open to allow the operation to proceed.

For benign polyps, the growth is essentially ‘skinned’ from the bowel muscle wall in one piece. For cancers, a full thickness excision is performed with a good rim of healthy tissue around. Occasionally this internal wound is stitched closed; however, sometimes we leave this wound open to heal slowly.

What is the recovery like after surgery?

It is usually a day case procedure and so you will be able to go home later that day. As with a colonoscopy procedure, your abdomen will feel bloated and gas filled when you come around from the anaesthetic. It is important to get up as soon as possible and walk around. We usually recommend a quick trip to the toilet to let off the gas.

Over the next 2-3 days you may experience some anal discomfort and pain. You may also experience some spot bleeding from the rectum. In most cases this settles within a week. If it gets worse rather than better we would recommend attending A&E or contact your healthcare provider for referral to surgical hot clinic for a review.

A small percentage of patients experience a temporary fever. We recommend taking paracetamol for a few days if this occurs.

Your bowels may take up to a week to start working. This is because of the bowel preparation taken before your operation. You can return to a normal diet straight away. You may be fit to drive after 1 week and to return to work after 2-4 weeks. You will be issued with a discharge summary and a copy will go to your GP. Pathology results from the removed growth will usually take 2 weeks.

Normal follow up after this procedure will involve a flexible sigmoidoscopy in the endoscopy department, usually by the surgeon who has performed the operation. This will happen three months after surgery. You will be given a phosphate enema to prepare your bowel for this follow up test.

What are the results like from surgery?

For patients with benign polyps, the surgery is usually curative. Patients under 75 years can expect to be invited for an endoscopy ‘screening’ programme as they may be at risk of developing further polyps in future.

For patients with rectal cancer, this operation can be curative for very early cancers. For more advanced rectal cancers that are still small in size, this operation is not standard. Usually major surgery would be recommended. Currently there are trials underway evaluating the safety of this technique in such cancers. Some patients with more advanced but small, rectal cancers have opted for this technique as an alternative to major surgery. In North Bristol we have treated a small percentage of patients with rectal cancer in this way. At this early stage, the risk of developing recurrent rectal cancer in patients undergoing this surgery is low.

We cannot predict which patients, if treated this way, will develop a recurrence and need further surgery. For these patients a close follow up programme is offered involving regular flexible sigmoidoscopy, MRI and CT scans.

What are the risks and long term effects of surgery?

This operation is usually well tolerated by patients, regardless of age. Patients can expect to be discharged the same day and are usually back to their normal selves within a week.

All surgery has risks and it is important to be aware of these risks before agreeing to surgery.

Specific complications

• Bleeding (usually spotting for 3-5 days then should stop).
• Pain around rectum/anus (common, should settle).
• Abdominal bloating (should settle in 24 hours).
• Infection (rare), transient temperature (more common).
• Urinary retention (increases with age, occasionally may need to be discharged with a catheter).
• Faecal urgency (this usually settles after 1 week).
• Faecal incontinence (rare).

Cancer patients

This biggest risk of choosing this operation over standard abdominal surgery is the risk of the cancer coming back either in the scar or spreading to nearby lymph nodes. For most patients with rectal cancer, this risk is low. For a small group of patients this risk may rise to 30%. All patients are offered a close follow up programme.

International studies have suggested that it should be possible to still perform major surgery if a cancer returned in the rectum after undergoing trans anal surgery. This issue will be discussed with you in depth prior to undergoing this procedure.

Is anyone not suitable for surgery?

We have operated on patients ranging in age from 35 to 90 years. It is well tolerated in all age groups. Sometimes it may not be possible to perform trans anal surgery. This may be because the growth is too large to be safely removed using this technique.

In a small percentage of cases we would need to perform major abdominal surgery (anterior resection) to remove your rectum instead. This operation carries significant risks – stoma formation (40%), anastomotic leak(<8%), damage to other structure in the abdomen and death (<2%).

Is there an alternative to trans anal surgery?

Yes, many centres recommend major abdominal surgery in order to remove the rectum/growth. This is standard treatment however carries significant risks with regard to recovery and longer term bowel function.

Is the operation painful?

As with all operations, you should expect some pain; usually this is localised to the anus. Taking over the counter painkillers such as paracetamol regularly will help. Your discomfort should settle down after a week.

If you have any concerns about ongoing symptoms or you are unsure about anything after surgery, contact your healthcare professional for advice.

How to contact us

Enhanced Recovery Nurses

Monday - Friday, 7:30am - 3:30pm

Telephone: 0117 414 3610 or 0117 414 3611

Telephone: 07808 201713

© North Bristol NHS Trust. This edition published July 2022. Review due July 2025. NBT003237

This page has been provided to give you information about the reversal of your small bowel stoma (ileostomy) or large bowel stoma (colostomy).

Your stoma is a connection between the bowel and the skin, which was formed temporarily at your previous bowel surgery.

Temporary stomas are created for a minimum of six weeks. It takes this time to allow for the swelling of the tissues to settle down. Some stomas may not be reversed for several months for various reasons including your general health and recovery from the surgery. If your operation was performed for cancer, further treatment such as chemotherapy may also delay the reversal.

Closing or reversing the temporary stoma is no doubt something you are eagerly awaiting. Many people see it as an indication of getting back to normal. Whilst this operation may be more straightforward and much shorter than your initial operation, there are still a few things to consider before surgery. It is important to be prepared for any potential side-effects which could develop after the operation and for you to know what to do if they occur.

Ideally, as many people as possible will have their bowel joined back up, but there could be reasons why your surgeon may be reluctant to do so. This will be discussed with you in person if this is the case.

The main considerations for the stoma reversal are:

• The doctors must be happy that you are fit enough for another operation.
• The bowel that your temporary stoma was created to protect has healed or improved since the first operation.
• The anal sphincters which control the flow from your bowels are working, so that loss of control of your bowels (faecal incontinence) will not develop afterwards.

Depending on what operation you have had, the surgeon may need to perform a rectal examination, and possibly arrange some further tests before making this decision.

What does the operation involve?

The closure of your stoma is ‘technically’ not as demanding as your previous surgery when the stoma was created.

This operation involves making a cut around the stoma, to free it from the abdominal wall and stitching the bowel back together to restore continuity, the stitching may be referred to as an anastomosis. The joined bowel is dropped back inside the abdominal cavity. This is followed by the stitching of the abdominal wall muscles and skin. It is still considered a significant operation.

Very occasionally it is necessary to reopen the original laparotomy wound scar to be able to reverse the stoma.

Alternatives to surgery

The alternative to this surgery is not having the stoma reversed and keeping the stoma. Around 1 in 12 patients who have had a planned temporary stoma for cancer of the rectum will keep a permanent stoma.

Preparation for your surgery

Before coming into hospital you will attend a pre-admission clinic. At this appointment you will be asked questions about your general health and you might have a chest x-ray, ECG (heart tracing) and blood samples if necessary. Most concerns can be addressed at this appointment but if you have further questions relating to your operation, you can contact your colorectal specialist nurse or one of the stoma team (contact numbers are at the bottom of the page).

You will be admitted on the day of your operation. You must not eat anything for 6 hours prior to your surgery, you can continue to drink water up to two hours before your operation. It is important that you drink plenty of fluids and eat well during the previous day.

The operation usually takes around 90 minutes. After your operation you will be taken to the recovery area for close observation before returning to your hospital ward.

What to expect after surgery

You may have a drip in your arm to give you fluids until you are drinking. Once you are awake you can eat and drink normally, you may find small, light, low fibre meals are better tolerated.

Most people are moderately sore at the reversal site afterwards, but this can be managed with pain killers. You may feel distended following the procedure, some patients describe this as a feeling of being “bruised and bloated” but as the swelling decreases this discomfort will ease.

On discharge from hospital you will be given some pain killers and a low fibre diet sheet to take home with you. You will also be provided with contact numbers for who to call if you encounter any problems.

Possible complications following surgery

As with any surgery, the operation to close your stoma has some risks which you need to be aware of. Your surgical team will take all possible steps to prevent them from happening.

General complications that can happen after surgery include:

• Deep vein thrombosis (DVT) is a blood clot in the leg which can occasionally move through the blood stream and into the lungs causing a pulmonary embolism (PE). Whilst you are in hospital you will have an anti-clotting injection daily and support socks to prevent this happening.
• Chest infection.
• Urinary tract infection (UTI).

These complications are avoided by early mobilisation and deep breathing. Getting up and walking around and out of hospital quickly can help prevent these problems.

• Wound Infection.
• Bleeding from the operation site.
• Formation of a fluid or blood collection under the scar (seroma or haematoma).

These complications are not serious but are the most common. Infection would be treated with antibiotics and a collection of fluid will either be reabsorbed by your body or discharged through the wound. Wound infection would usually occur after you have gone home so if the wound becomes hot, red and sore please see your GP or practice nurse for further advice.

Complications following reversal of stoma

Hernias

A hernia occurs when the bowel protrudes through the muscles of your abdomen causing a bulge beneath the skin. The hernia may reduce or increase in size when lying, sitting, or standing. Hernias occur at sites of potential weakness (the stoma reversal site or at the scar of the first operation). The risk of a hernia formation is small but is more likely in frail, older and overweight patients. Its also seen more frequently in those who have strained their bodies or have undertaken too much exercise in the first few weeks following surgery. Management includes supporting your hernia with a belt or binder. This helps with decreasing the protrusion and assists in maintaining a good posture.

Most hernias appear over subsequent months, generally developing within the first two postoperative years. Surgical repair may however be necessary in a proportion of patients.

Less common complications

Anastomotic leak

A leak from the stitching where the bowel is joined back together. This happens in 1 in 250 cases of stoma reversals. This is a more serious complication which usually requires further surgery. If this happens your stoma might need to be reformed. This does not mean that it will be permanent as depending on your general health, it is still possible for another attempt at reversal in the future.

If there is a leak, you will probably experience a dull pain in your pelvis (the area below your belly button and above your hips), have a fever, and feel lethargic.

This complication usually presents within a few days after the operation and can make you feel generally unwell.

Abdominal collection

This refers to a collection of infected fluid inside the abdomen and presents as worsening pain and bloating. You may also have a high temperature and either frequent loose stools or the bowels stop working. The management of this condition involves antibiotics and drainage of the collection using either an ultrasound or CT scan.

Ileus and bowel obstruction

Initially after the surgery there is the risk of the bowel not working properly. This is because of a delay in the bowel movement or contractions known as peristalsis. The cause of this condition is generally due to the handling of the bowel during the surgery and the bruising which creates swelling. It can take a few days before the bowel movements occur normally again and you start to pass both wind and stool from your back passage.

If an ileus or bowel obstruction occurs and your bowels temporarily stop working you may experience increased bloating, abdominal pain, nausea and vomiting. This can be managed by stopping dietary intake and allowing your bowel to rest. It may also be necessary to pass a small tube through your nose into your stomach to relieve the symptoms. Keeping mobile and chewing gum will help prevent an ileus. You can return to normal diet once your bowels start working again. We will not expect you to necessarily have opened your bowels before you go home, but we would expect you to be eating and drinking without significant abdominal bloating, nausea or vomiting.

Similar symptoms may occur in patients who develop a blockage in their bowel (bowel obstruction). An obstruction after surgery is generally caused by adhesions (sticking of bowel tissue) or kinking of the bowel. In most cases the initial management is the same as described above for an ileus. In the majority of cases the bowel obstruction will also settle down on its own. A small percentage of patients will require a further operation or intervention.

If you are at home and are worried about any of the symptoms or complications described please contact us on the numbers provided in this leaflet for further advice. Readmission to hospital may be necessary if your symptoms are causing you to feel unwell and there is a suspected deterioration in your health, such as you can no longer tolerate fluids.

Fistula formation

A fistula is an abnormal connection between two parts of the body, in this case it is often from the bowel to the surface of the skin. In rare cases problems from the join made during the first operation can occur once the stoma is reversed and continuity of the bowel is restored. The most common problem is caused from an infection around the rectal anastomosis (join) which can present as a fistula. Some fistulas can heal on their own but surgery may be considered if the fistula does not close within a few months.

Possible side effects after stoma reversal

Diarrhoea

After the reversal it is common to experience liquid bowel motions for the first few days up to a few weeks before it settles down. In a small percentage of patients it can take up to 6 months before the bowel motions become more firm. It is fairly common to pass looser and more frequent stools than you may have been used to previously. Adjusting the food you eat and taking bowel slowing medication can help with this.

Frequency and urgency

It is normal to have erratic bowel movements for several weeks after this operation. You may find that you need to go to the toilet more urgently and also more often. This can be more of a problem for those who have had a low join or anastomosis in the bowel and for those who have had pelvic radiotherapy and/ or were already suffering from a weak sphincter muscle. The patients who have weak pelvic floor and anal sphincter muscles may leak gas, liquid or solid stools.

Performing pelvic floor exercises may help to regain continence but need to be practiced at least five times a day and over a few months to be of benefit. (Separate leaflets on how to exercise the pelvic floor are available). When done correctly, these exercises can build up and strengthen the muscles to help you to hold both gas and stool in the back passage.

Good hygiene and a light barrier cream may be useful to prevent the skin becoming sore if you are experiencing loose and frequent stools.

How long will you stay in hospital?

Our aim is that most patients who have an ileostomy reversal would go home after staying one night in hospital. You will be seen by your team of doctors the morning after your operation and a decision will be made to send you home if you are ready for discharge. This would usually be in the afternoon or early evening, but this may be earlier if you are well.

As long as you are tolerating fluids and a light diet, are mobile, have passed urine and are reasonably comfortable on pain killing tablets then you can go home.

Symptoms to look for once discharged home

Occasionally patients need to be re-admitted to hospital following discharge home due to complications such as an anastomotic leak, abdominal collection or obstruction.

Acute and persistent symptoms will require further observation and investigation.

The symptoms which should alert you include:

• Progressive and worsening abdominal pain.
• Increased bloating and abdominal discomfort.
• Persistent nausea and vomiting.
• High temperature.
• Breathing difficulties.
• Feeling generally unwell.
• Unable to eat and drink sufficiently.
• Persistent loose stools and diarrhoea.
• New difficulty with passing urine

Early detection of a serious complication leads to a better recovery, so if you feel unwell please contact The Enhanced Recovery Team for advice (contact numbers are at the bottom of the page). Out of office hours, please contact the surgical admissions unit.

We would prefer that you talk to us in the first week after discharge rather than your GP so we can identify problems early and bring you back to hospital if needed. Where possible, we will ask your GP to help to save you a trip to hospital.

Eating and drinking

Once you are home you should gradually build up to a normal diet. In general, you are advised that for the first couple of weeks after your operation you should reduce the amount of fruit, salad and vegetables that you eat. These types of food contain fibre and will be hard for your bowel to digest initially. Meal snacks like crisps and biscuits are good to nibble on when you start eating. The main advice is to eat little and often until your appetite returns to normal and you feel able to return to a healthy balanced diet.

You may find your sense of taste and smell is altered following the surgery. This can be because of the antibiotics, anaesthetics and painkillers. Be reassured that your taste and appetite will return to normal within approximately six weeks.

A good fluid intake of eight cups a day (some of which should be water) is advised. However if you experience constipation, you may need to drink more.

If any particular food does seem to cause problems (such as frequency) just stop eating it for a while, then try again at a later date.

Caring for your wound

It is good idea to inspect your wound daily once you are home. Keeping the wound dry and clean will help prevent infection. You may apply a dry dressing for the first week, which is usually changed after showering. The nursing staff will be able to provide you with a small supply if required.

If you are worried about possible infection, please call the ward for advice.

Signs of infection could be:

• Increased pain, swelling or inflammation.
• Redness around the wound.
• Discharge of fluid or pus from wound.

Exercise

It is very important that you start to walk around as soon as you can after the surgery, as this helps your breathing and circulation, as well as helping you to regain your strength. It is normal to feel tired after surgery so consider what help or support you may need when you go home.

When you first get home after your operation, initially plan your day to have a rest in the afternoon. It takes time to regain your normal strength, so try to build up to the amount of exercise you do slowly. Some people find it helpful to set goals to reach each week, for instance start by going for a short walk each day and increase this distance once you feel able. The level of exercise you will be able to do will vary dependent on your level of fitness before surgery. If you participate in strenuous sports or exercise, you should generally wait six weeks and then introduce this back into your lifestyle gradually.

Having had surgery on your abdomen, you are advised not to lift for the first six weeks. It is important that you do not do any heavy lifting (no heavier than a half-filled kettle) for at least two weeks following the operation, and build up gradually. The concern is that if you put too much stress on your abdominal muscles, you may cause a permanent weakness, which may lead to a hernia in the old stoma site.

Driving

You can drive as soon as you are able to concentrate fully and can make an emergency stop without discomfort in your abdomen. A minimum of two weeks is suggested however it is advisable to check with your own insurance policy as some insurance companies state that you will not be covered for six weeks after any abdominal surgery.

Returning to work

You can return to work when you feel ready to. However you may be surprised at how tired you feel after this operation, so it is advisable to consider returning to work on a part-time basis for a few weeks. If you have a physically demanding job or involves heavy lifting, it is preferable not to consider going back to work for six weeks, and to request lighter duties if possible. This will initially allow you to build up to your stamina and strength for normal duties.

Resuming sexual intimacy

The anxiety and all the stress your body has been through with this operation often reduces your sex drive. This is quite normal and in time it should return. It is important that you and your partner share time talking about your feelings, being close and enjoy being intimate without necessarily having penetrative sex. Once your body feels fitter and more relaxed, you may feel more confident resuming your usual sexual activity again. If you do experience any problems in having sex with your partner, please do discuss this with your doctor.

Follow up care

When you are initially discharged home, some people find it helpful to have family member or friend to stay. Extra help for this first week at home will allow you to rest when you will feel tired and may help you recover sooner. After this, you may still need help with the shopping, cooking and cleaning for a couple more weeks. But remember it is important for you to stay as active as possible.

If you have any queries or questions, do not hesitate to contact your surgical team or GP.

How to contact us

• Enhanced Recovery Nurses: 0117 414 3610 / 0117 414 3611 or 07808 201713
• Stoma Office: 0117 414 0270
• The Surgical Admissions Unit, Gate 32B: 0117 414 3233
• Switchboard: 0117 950 5050

© North Bristol NHS Trust. This edition published January 2024. Review due January 2027. NBT002926

Your estimated discharge date

The Enhanced Recovery Nurses will discuss your estimated discharge date with you.

Introduction

This information aims to increase your level of understanding of how you can play an active part in your recovery, after your emergency surgery. If there is anything that you are unsure about, please ask. It is important that you understand how you can help yourself recover, so that you, your family and friends can be involved.

Enhanced Recovery is a programme offered by North Bristol NHS Trust for patients undergoing emergency bowel surgery. Having surgery as an emergency can be stressful, and this information will help your recovery.

What is Enhanced Recovery?

The aim of Enhanced Recovery is to get you back to full health as quickly as possible after your operation.

Research indicates that after surgery, the earlier we get you out of bed, exercising, eating and drinking, your recovery will be quicker and it will be less likely that complications will develop.

Some of the benefits include:

• A quicker return of normal bowel function.
• Reduced chest infections.
• A quicker return to usual mobility.
• Decreased fatigue.
• Reduced risk of developing blood clots after surgery.

In order to achieve this we need you to be partners with us, so that we can work together to speed up your recovery.

Before your surgery

There is evidence to suggest that keeping warm, before surgery, helps prevent infection. Please ensure you have a warm dressing gown or similar item of clothing to wear immediately before your operation.

If possible, please ask a relative or friend to also bring you a supply of comfortable ‘day clothes’ for after your operation. You will be encouraged to return to normality as quickly as possible, and this includes getting dressed.

Eating and drinking

In preparation for your operation, if you are allowed to eat and drink normally, you should aim to take 3 of the Fortisip or Fortijuce supplement drinks per day. The drinks will be supplied by the ward for two days before your surgery.

The supplement drinks are important to help with wound healing, to reduce the risk of infection and aid with your overall recovery. It is important that you also continue to have a variety of other non-fizzy drinks during your hospital stay.

As well as the supplement drinks mentioned, you will also be required to take special carbohydrate drinks called ‘Pre Op’. You will require two drinks the night before and 2 drinks on the day of your operation, three hours before surgery. If your operation is very urgent, you may only be given two ‘Pre Op’ drinks before surgery.

You may continue to eat for up to six hours before your operation and drink fluids for up to three hours before, unless otherwise directed by your doctor.

A few hours after your operation you will start to drink and eat if you wish. It is important that you eat and drink early after your surgery, however if your operation was for a blockage in the bowel, early eating may not be appropriate. The ward staff will help and advise you. You will be expected to recommence the supplement drinks to help build up your strength. The drinks will either be given to you by the ward staff or you can help yourself to the drinks from the patients fridge.

Studies show that chewing gum after an operation can be helpful towards improving your recovery by assisting the bowel to return to its normal function.

Please ask a relative or friend to bring some chewing gum in for you. After your operation chew gum for 15 minutes, three times a day, until your bowel function returns to normal.

Preparing for theatre

On the day of your operation you may be given an enema to empty your bowel contents.

In order to help prevent blood clots you will be required to wear special support stockings (TEDS). The nurse will need to measure your legs to obtain the correct size.

You will also be given a small injection called ‘clexane’ at approximately 6pm each day you are in hospital. This helps reduce the risk of blood clots by thinning the blood.

Some patients who are at higher risk of experiencing blood clots may have to continue with the injection once home. This would only be for a few weeks after surgery and will be fully discussed with you when you are in hospital. Most patients are able to administer the injection themselves or with the help of a relative or carer. The nurses on the ward will show you how to use the injection during your hospital stay. If you have any problems with administering the injection an appointment can be made with your practice nurse to carry this out each day, or we will arrange for a District Nurse to visit you if you are unable to leave the house.

It is important that you keep yourself warm before your operation and you are advised to dress accordingly, (warm dressing gown, socks, slippers, blankets). You will be asked to remove the warm clothing when it is time for your operation as you will be required to wear a hospital gown.

After your operation

Mobilising and exercising

Following your operation when you wake up, it is important that you do deep breathing exercises (as prevention against chest infection). You will need to do 5 deep breathing exercises every hour. To do these you will need to:

• Be in an upright position.
• Take a deep slow breath in (feel your stomach gently rise).
• Hold the breath for 3 seconds.
• Breathe out slowly.
• Repeat 5 times.

You should cough regularly to make sure your lungs are clear of secretions. To do this, place a towel or pillow over your abdomen and wound. Support it with your hands and cough.

When you are sitting in the chair or lying in bed, you should also do frequent leg exercises, (as prevention against blood clots) pointing your feet up and down and moving your ankles as if making circles can achieve this.

Depending on what time you come back to the ward, the staff will help you out of bed about six hours after your operation. You may sit out of bed for up to two hours on the day of surgery and then up to six-eight hours out of bed on each subsequent day after surgery if you can manage this.

You will be encouraged to walk at least 60 metres four to six times per day after your surgery if you can manage this. By being out of bed in a more upright position and by walking regularly, lung function is improved and there is less chance of a chest infection after surgery. Circulation is also improved, reducing the risk of a blood clots and helping bowel function return to normal.

Try wearing your day clothes as soon as you feel able after your operation as this can help you feel positive about your recovery.

Pain control

It is important that your pain is controlled so that you can walk about, breathe deeply, eat and drink, feel relaxed and sleep well. Please let us know if your pain is not manageable so that we can help you.

It is also important for us to know if you are either allergic or sensitive to certain pain killers.

You may be given one of, or a combination of the following methods of pain relief, to keep you comfortable after surgery:

• Patient controlled analgesia (PCA). This is an intravenous pain killing medication, delivered by a machine, which is set up so that you can control it yourself. You will be given instructions on how to do this.
• Tap block. This is an injection given at the time of your operation to temporarily numb the abdomen and keep you comfortable immediately afterwards.
• Spinal block. This is an injection given at the time of your operation that will temporarily numb you from the waist down and will keep you comfortable afterwards.
• Ketamine infusion. This is a continuous intravenous pain killing medication which will run up to 24 hours after surgery.

The anaesthetist may discuss these options with you and explain more about it whilst you are in hospital, before your operation.

Alongside this, the doctors will prescribe other types of pain relieving medicines, which work in different ways. You will be given these regularly (three or four times per day) and you should feel more comfortable.

If the pain worsens at any time, please tell the nursing staff immediately and they will be able to help you.

Sickness

Sometimes after an operation it is not uncommon to feel nauseated and occasionally vomit. You will be given medication during surgery to reduce this, but if you feel sick following surgery please tell a member of staff who will be able to help.

Tubes and drips

During your operation a tube (catheter) will be placed into your bladder so that we can check that your kidneys are working well and your urine output can be measured. This tube will be removed as soon as possible.

You will have an intravenous drip put into your arm to ensure you do not become dehydrated. The drip will normally be removed the day after surgery, but you may still have the intravenous port (venflon) in place for a couple of days in case we have to give other drugs through it.

It is possible you may return from your surgery with a tube in your nose. The tube may stay in a few days which will help drain your stomach if your surgery was due to a blockage or an emergency. We aim to remove the tube as soon as possible. Please wait until the tube is removed before trying to eat. Staff can advise.

You may also be required to breathe extra oxygen for a short while after your operation.

Monitoring

Many different things will be monitored during your treatment including:

• Observations (blood pressure, pulse, temperature).
• Fluid in.
• Fluid out.
• Food eaten.
• When your bowel first starts working or you pass wind.
• Pain assessment.
• Number of walks achieved.
• Time spent out of bed.

You may be asked to tell us about what you eat and drink and what you pass so that we can record it.

Whilst you are in hospital you will be asked to participate in maintaining a daily diary / log (provided by the ward), so that you can keep a record of how well you are managing. This will help us monitor your progress.

Please remember playing an active part in your recovery will help you get better sooner. If you have any questions regarding your recovery please do not be afraid to ask a member of staff.

References and further information

For further information on the Enhanced Recovery Programme you may access the following websites:

www.nbt.nhs.uk/erp
www.gov.uk/government/organisations/department-of-health-and-social-care

How to contact us

Brunel building
Southmead Hospital
Bristol BS10 5NB

Surgical Admissions Unit
Gate 32B
Telephone: 0117 414 3233

Enhanced Recovery Nurses
Telephone: 0117 414 3610
Telephone: 0117 414 3611

Colorectal nurses
Telephone: 0117 414 0514

Stoma Care Nurses
Telephone: 0117 414 0270

© North Bristol NHS Trust. This edition published January 2024. Review due January 2027. NBT002721

What is cell salvage?

Cell salvage is a method of collecting blood you have lost during an operation, so that it can be given back to you.

The blood collected is washed and filtered to remove any contaminants. This blood can then be given back to you if the doctor thinks a blood transfusion is required. It is sometimes called autologous blood transfusion (using your own blood).

Cell salvage is a technique that is well established in many types of surgery and is regularly used at Southmead Hospital.

Why might I need a transfusion?

It is normal when having major surgery to have some blood loss during the procedure. In some cases this can be a large amount and will require the blood to be replaced by giving a blood transfusion. Blood used for these transfusions can either be:

• A supply of donor blood from volunteers; or
• Your own blood (by using cell salvage blood).

What are the benefits of using cell salvage blood?

Use of cell salvage can reduce the need for a blood transfusion using donor blood, which is in short supply and expensive.

Although the risk associated with receiving a blood transfusion from a donor are low, there are still a very small risk of infections being passed on (1:500,000 for Hepatitis B, 1:30 million for Hepatitis C, 1:5 million for HIV, less than 1:2 million for vCJD). Having your own blood returned to you removes these risks.

Likewise donor blood is stored before transfusion and this affects its properties. For instance, stored blood does not carry oxygen as well. Having your own blood returned to you straight away reduces these problems.

The cell salvage technique is sometimes seen as an acceptable alternative for those who for religious reasons will not accept a blood transfusion using donated blood.

Why isn’t it suitable for everyone?

Not all operations result in enough blood loss to enable cell salvage to be used. For some operations cell salvage is not recommended e.g. some bowel surgery.

What does this mean for you?

This information aims to help you make an informed decision on whether you would prefer cell salvage blood should you need a blood transfusion during your operation.

If you have any questions about cell salvage which are not answered by this information, please discuss them with your anaesthetist.

The following video will show you how to use P 6 acupressure to prevent or treat post-operative nausea and vomiting. It has been proven, by statistically summarising the results of 40 trials including 4858 patients, that this technique is as good in preventing or treating post-operative nausea and vomiting as taking an anti sickness medication. That does not mean that it will work for every patient, but it is worth trying first before you use some anti-sickness medication. 

• To find your acupressure points, you can take your index, and middle finger and place it on your wrist at the base of your palm.
• Alternatively, you can find them by identifying the two tendons in your wrist going in the middle of these and either going two or three finger widths from the crease in your wrist; this is your acupressure point.
• Take your thumb and your index or middle finger and press firmly on the points on both sides of the wrist. Do this when you feel nauseous and you should get relief within ten to thirty seconds, sometimes it can take a bit longer, up to five minutes.
• Alternatively, you can tap your wrists together gently at the acupressure points whilst taking deep breaths.